Summary

In early summer 2004, a 12-year-old boy was killed while helping a farmer,
his uncle, hitch a hay wagon to a truck. They had been baling hay the
day before and, next morning, were preparing to unload the hay bales from
the hay wagon/hayrack, which was parked in the farmyard (Photo
1). The farmer was driving a 1-ton flatbed truck, which he had just
backed up to the front of the hay wagon. The boy jumped out of the truck
to hitch up the wagon, and when he lifted the tongue on the wagon, the
wagon apparently started to slowly roll forward toward the truck. The
boy failed to get the tongue hitched to the rear of the truck, and the
wagon continued its slow forward roll, pinching the boy’s head between
the wagon and the rear of the truck’s metal bed. The farmer, sitting
in the driver’s seat of the truck, felt nothing unusual. Suddenly,
not seeing the boy, he jumped out and ran back to find him slumped over
the tongue of the wagon, and a large pool of blood on the ground. The
boy was dead at the scene. The tongue of the wagon had bulldozed into
the ground, indicating that the wagon had moved forward (Photo
2).

Photo 1 – Side view of the loaded hay wagon
at rest on nearly flat ground in the farmyard.

Recommendations based on our investigation are as follows:

Farm wagons without parking brakes should always have their wheels
chocked to prevent them from rolling, especially when parked on rolling
or sloping ground.

When hitching wagons to towing vehicles, farmers and farm workers
should stand safely to one side, out of the hitching area, where they
can see the hitch and communicate directions to the vehicle operator.

Manufacturers of farm wagon running gear and other wagons should consider
providing parking brakes, chocks, or other reliable means to secure
wagons when they are parked.

Introduction

During the summer of 2004, a 12-year-old farm boy was working for his
uncle when he was crushed between a hay wagon and a truck bed. The Iowa
FACE program was alerted to this incident by a colleague, and an immediate
investigation was begun, gathering information from newspapers, the County
Sheriff, and the State Medical Examiner’s Office. Contact was made
with the farmer who owned the farm. However, a site visit was not conducted
since excellent information and photographs were obtained from the county
sheriff.

The uncle was a farmer who managed 700 acres (285 hectares) of land planted
in corn, soybeans, and hay. He had been working and living with his family
at this location for the past 25 years. The boy was one of several neighbor
boys who had worked at the man’s farm over the past several years.
On the day of this incident, the farmer was also working with a neighbor
and another 16-year-old boy, for a total work crew of four, baling hay
early in the summer.

There was no official safety program or written policies for employment
at this small farm. Several local farm boys were frequently hired for
odd jobs on an hourly basis, and paid in cash. The farmer had significant
construction experience, and he would often hire 6 or 7 boys throughout
the summer to assist with various farm and related construction projects.

Photo 2 –
Front view of the hay wagon, showing
the tongue, which had bulldozed into the
ground as the wagon rolled forward.

Investigation

On the day prior to this incident, the work crew of four had baled about
800 bales of hay, using a conventional square baler, which creates bales
that weigh about 40-60 lbs (18-27 kg). They had baled several loads of
hay and, early the next morning, were in the process of moving this hay
into storage. The 12-year-old boy was big and strong for his age, and
could easily handle the hay bales. Nonetheless, the farmer would move
bales stacked too high for the helper, and leave the lower bales for the
boy, who was earning extra money to attend the county fair.

The hay wagon was a typical wooden rack on a standard running gear with
a metal tongue and clevis hitch (Photo 2). The wagon
carried 100 bales of hay and was parked alone in the farmyard without
brakes or wheel chocks. The edges of the hay rack bed were covered with
1½ in. angle iron (Photo 3). The farmer and
boy worked approximately 30 minutes that morning before they drove to
retrieve the loaded hay wagon. The farmer drove his 1-ton straight truck
with flatbed box containing old pieces of plywood, a pallet, and several
bags of soybean seed. The plywood stuck out beyond the truck bed about
12 inches (300 mm).

Photo 3 - View
of rear of truck showing relative position of bumper and truck bed.
Hay wagon shown to the right is typical, but is not the one involved
in this incident.

The loaded hay wagon had been moved into the farm yard the day before
by the farmer and his wife. The farmer remembered pulling the hitch pin
himself, and seeing the tongue fall to the ground without the wagon continuing
to move. This area of the farmyard was flat (Photo 1),
not at all like other areas of his farm ground, which required all wagons
to be blocked against rolling. There was no indication that the loaded
hay wagon might roll.

The farmer backed his truck into position in front of the hay wagon and
the boy jumped out to hitch up the wagon. This was a simple task he had
done many times before. Looking into the side mirror, the farmer was communicating
with the youth when he suddenly lost sight of him. Exact details at this
point are hard for the farmer to recall, but he did not feel a collision
of any kind. He immediately pulled his truck forward a few feet, then
jumped out and ran behind to find the boy slumped over the tongue of the
wagon, and a large pool of blood on the ground. There was approximately
4-5 feet between the vehicles at this time. According to the farmer, the
boy hardly had a mark on him, but was not breathing. It was determined
later that he had died instantly from a head injury. There was no damage
to the truck or the hay wagon, or any signs of direct collision of the
two vehicles.

Measurements taken at the scene showed the front of the loaded hay wagon
at 35--36½ inches (890-930mm) above the ground, and the rear of
the flat bed truck at 34¾--39 inches (880-990 mm) above the ground
(Diagram 1). Given these measurements, and the
description by the farmer, it is possible the hay wagon slowly rolled
just close enough towards the rear of the truck, but without touching
it, to fatally injure the boy as he bent over the wagon tongue to guide
it toward the pickup’s hitch and drop the hitch-pin in place. Once
pushed, bumped, or rocked back in the tracks into which it had settled,
been pulled, or otherwise set in motion, even a slow-moving wagon can
be difficult to stop.

Diagram 1 -
Shows the relative positions of the
truck and hay wagon per measurements taken
by Sheriff’s investigators.

Cause of Death

The cause of death from the medical Examiner’s report was, “neurogenic
shock due to acute cranial cerebral blunt force trauma due to a farm accident.”

Recommendations/Discussion

Recommendation #1: Farm wagons without parking brakes should always
have their wheels chocked to prevent them from rolling, especially when
parked on rolling or sloping ground.

Discussion: The farmer assumed that the area of his
farmyard in Photo 1 was flat. While it appears flat
in the photograph, the terrain under the wagon apparently sloped slightly
away from the front of the wagon, as evidenced by the tongue, which was
found dug into the dirt after the wagon had rolled (Photo
2). On ground that was obviously sloped, the farmer always used wheel
chocks, but he never considered them at this location because of the flat
appearance of the terrain. When the wagon was unhitched and left in position,
the tongue would have dropped to the ground and dug in slightly if the
wagon had continued to move from its own momentum. However, the wagon
did not appear to have moved appreciably, and the farmer may have assumed
it to be stable and at rest on flat ground, even though there may have
been a forward push on the tongue. The direction of the forces on this
wagon could have changed while the wagon sat overnight in the farmyard
as the wheels settled into the ground. It is possible that, initially,
the tongue was holding the wagon in place, and when the boy picked it
up, the wagon began to move.

Experienced farmers in this situation would typically lean against the
wagon to slow or stop it before it struck the truck, stick the tongue
back in the dirt as a temporary stop, or jump out of the way if the wagon
continued to roll. A less experienced 12-year-old boy may not know these
techniques or be able to employ them. The seemingly simple job of hooking
up a wagon evidently became a complex maneuver of trying to manage the
moving tongue of the hay wagon with one hand, and working with a hitch
pin in the other hand, hoping they would somehow come together with the
wagon properly hitched to the truck.

Leaving farm wagons un-chocked is somewhat like parking a motor vehicle
with its manual transmission in neutral without engaging the parking brake,
something that is rarely done for fear the vehicle might roll away. Wheel
chocks should be regular equipment for all farm wagons and other vehicles
which do not have built-in parking brakes. Farmers should develop a habit
of using them on a regular basis even on “flat ground”, remembering
the tragic consequences evident in this case. On ground that is obviously
sloped, one should block all four wheels against movement with substantial
chocks or other means to guarantee the wagon will stay put.

Recommendation #2: When hitching wagons to towing vehicles, farmers and
farm workers should stand safely to one side, out of the hitching area,
where they can see the hitch and communicate directions to the vehicle
operator.

Discussion: The routine hitching procedure requires
moving the truck (or a tractor) close to the wagon, then parking and dismounting
to make the connection. This task can be less difficult when the truck’s
hitch or the wagon’s tongue accommodate misalignment, such as with
a tractor where the tongue can be swung into place from the side of the
drawbar.

In the common alternative, an assistant moves between the wagon and the
truck to guide the tongue into place as the truck inches rearward, dropping
the hitch pin into place to make the final coupling. This process relies
on good communication between the assistant and truck driver, and complete
control of the truck’s movement. To avoid repeat incidents similar
to this case, the assistant should guide the driver while remaining outside
of the area between the moving truck and the wagon. Once the truck is
nearly to the right position, the assistant should evaluate the relative
positioning, and then instruct the driver to make the final adjustments
and secure the truck against movement before moving between the truck
and wagon to drop the hitch pin into place. This method decreases the
risk of injury from being struck by the towing vehicle. However, it does
not remove the risk of being struck by an un-chocked wagon.

Recommendation #3: Manufacturers of farm wagon running gear and other
wagons should consider providing parking brakes, chocks, or other reliable
means to secure wagons when they are parked.

Discussion: Wagons are often disconnected from tractors
and other towing vehicles on sloping terrain where, initially on unhooking,
they may move forward or backward. Manufacturers of such running gear
and wagons should provide means such as chocks or parking brakes to ensure
they remain parked. Providing chocks and a proper, easily accessible storage
location for them, would, when routinely and properly used, improve safety
for farmers and farm workers.

Iowa FACE Program

Fatality Assessment and Control Evaluation, FACE, is a program of the
National Institute for Occupational Safety and Health (NIOSH),
which is part of the Centers for Disease Control and Prevention of
the U.S. Department of Health and Human Services. Nationally, the
FACE program identifies traumatic deaths at work, conducts in-depth studies
of select work deaths, makes recommendations for prevention, and publishes
reports and alerts. The goal is to prevent occupational fatalities across
the nation.

The NIOSH head office in Morgantown, West Virginia, carries out an intramural
FACE case surveillance and evaluation program and also funds state-based
programs in several cooperating states. In Iowa, The University of
Iowa through its Injury Prevention Research Center works
in conjunction with the Iowa Department of Public Health and its Office
of the State Medical Examiner to conduct the Iowa FACE program.

Nationally, NIOSH combines its internal information with that from cooperating
states to provide information in a variety of forms which is disseminated
widely among the industries involved. NIOSH publications are available
on the web at http://www.cdc.gov/NIOSH/FACE/
and from the NIOSH Distribution Center (1-800-35NIOSH).

Iowa FACE also publishes its case studies, issues precautionary messages,
and prepares articles for trade and professional publication. In addition
to postings on the national NIOSH web site, this information is posted
on the Iowa FACE
site. Copies of FACE case studies and other publications are available
by contacting Iowa FACE, too.

The Iowa FACE team consists of the following specialists from the University
of Iowa: Craig Zwerling, MD, PhD, MPH, Principal Investigator; John Lundell,
MA, Co-Investigator; Murray Madsen, MBA, Chief Trauma Investigator; and
Co-Investigator/specialists Risto Rautiainen, PhD, and Wayne Sanderson,
PhD, CIH. Additional expertise from the Iowa Department of Public Health
includes Rita Gergely, Principal Investigator, and John Kraemer, PA, from
the Office of the State Medical Examiner.